Nokea
The nurse is caring for a client with a diagnosis of postpartum endometritis. Which vital sign change is most likely to be observed?
- A. Fever
- B. Tachycardia
- C. Hypotension
- D. All of the above
Correct Answer: D
Rationale: Postpartum endometritis a uterine infection can cause fever (from infection) tachycardia (from systemic response) and hypotension (in severe cases). All vital sign changes may be observed.
You may also like to solve these questions
A client with a history of a stroke is being taught to use a quad cane. The nurse should teach the client to:
- A. Hold the cane in the strong hand
- B. Advance the cane with the strong leg
- C. Use the cane on the weak side
- D. Lean heavily on the cane
Correct Answer: C
Rationale: The quad cane should be used on the weak side to support the affected leg post-stroke, improving balance. Holding in the strong hand or advancing with the strong leg is incorrect.
A 10-year-old client with a pin in the right femur is immobilized in traction. He is exhibiting behavioral changes including restlessness, difficulty with problem solving, inability to concentrate on activities, and monotony. Which of the following nursing implementations would be most effective in helping him cope with immobility?
- A. Providing him with books, challenging puzzles, and games as diversionary activities
- B. Allowing him to do as much for himself as he is able, including learning to do pin-site care under supervision
- C. Having a volunteer come in to sit with the client and to read him stories
- D. Stimulating rest and relaxation by gentle rubbing with lotion and changing the client's position frequently
Correct Answer: B
Rationale: Self-care is usually well received by the child, and it is one of the most useful interventions to help the child cope with immobility, providing a sense of control.
A burn client's care plan reveals an expected outcome of no localized or systemic infection. Which assessment by the nurse supports this outcome?
- A. Wound culture results showing minimal bacteria
- B. Cloudy, foul-smelling urine
- C. White blood cell count of 14,000/mm3
- D. Temperature elevation of 101°F
Correct Answer: A
Rationale: Minimal bacteria in wound cultures indicates no localized infection, supporting the outcome. Cloudy urine (B), elevated WBC (C), and fever (D) suggest possible infection.
A client with cancer is experiencing a common side effect of chemotherapy administration. Which laboratory assessment finding would cause the most concern?
- A. A sodium level of 50 mg/dL
- B. A blood glucose of 110 mg/dL
- C. A platelet count of 125,000/mm3
- D. A white cell count of 5,000/mm3
Correct Answer: A
Rationale: A sodium level of 50 mg/dL is impossible (likely a typo for 50 mEq/L, which is severely hyponatremic) and life-threatening, causing seizures. Glucose (B), platelets (C), and WBC (D) are near normal or less critical.
The nurse is preparing to administer insulin to a client with type 1 diabetes. The client is to receive 10 units of NPH insulin and 5 units of regular insulin in the same syringe. Which action is correct?
- A. Draw up the regular insulin first, then the NPH insulin.
- B. Draw up the NPH insulin first, then the regular insulin.
- C. Mix the insulins in a separate vial before drawing up.
- D. Administer the insulins in two separate injections.
Correct Answer: A
Rationale: To prevent contamination, draw up regular (clear) insulin first, then NPH (cloudy). Mixing in a vial (C) is incorrect, and separate injections (D) are unnecessary.